The role of preoperative pulmonary function tests in patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion.

STUDY DESIGN: A retrospective review of the case records and radiographs of 133 patients with adolescent idiopathic scoliosis who underwent posterior spinal fusion and instrumentation between 1986 and 1992. OBJECTIVES: To evaluate the incidence of abnormal results on preoperative pulmonary function tests and their correlation to immediate postoperative pulmonary impairment in patients with adolescent idiopathic scoliosis who had posterior spinal fusion. SUMMARY OF BACKGROUND DATA: It has been stated that preoperative pulmonary function tests are essential to assess surgical risk in a patient with scoliosis because of the possibility of further compromising the pulmonary function. Authors of previous studies have reported on the increased incidence of postoperative pulmonary complications in patients undergoing anterior spinal surgery. METHODS: The case records and radiographs of 133 patients with either a thoracic or a double-major curve, who underwent posterior spinal fusion, were reviewed. The presence of any preoperative or postoperative cardiopulmonary symptoms and increased requirement of postoperative ventilatory support were noted. Results of preoperative pulmonary function tests were classified as normal, restrictive, or obstructive disease. Postoperative chest radiographs were examined to note the presence of atelectasis, infiltrates, pneumothorax, hemothorax, or pneumonia. RESULTS: The majority of patients (72.9%) had normal results on pulmonary function tests. The mean coronal Cobb angle of the thoracic curve was 48 degrees, and the mean angle of kyphosis was 26 degrees. None of the patients had any increased requirement of postoperative ventilatory support. The overall incidence of postoperative pulmonary complications was 2.3%. CONCLUSIONS: Performance of a thoracoplasty was the only risk factor for postoperative pulmonary complications in patients undergoing posterior spinal fusion. There was no correlation between deterioration of preoperative pulmonary function and the risk of postoperative pulmonary complications. It appears that performance of preoperative pulmonary function tests in patients with moderate adolescent idiopathic scoliosis-scheduled for posterior spinal fusion is not necessary.

Comparison of push-prone and lateral-bending radiographs for predicting postoperative coronal alignment in thoracolumbar and lumbar scoliotic curves.

STUDY DESIGN: A comparative evaluation of supine right and left lateral-bending radiographs and push-prone radiographs in patients with thoracolumbar and lumbar scoliosis to determine postoperative correction of the curve. OBJECTIVES: To determine the difference in the ability of the push-prone radiograph and the supine lateral-bending radiograph to predict postoperative coronal alignment for primary thoracolumbar and lumbar curves managed with an anterior spinal instrumentation and fusion. SUMMARY OF BACKGROUND DATA: Right and left supine side-bending radiographs are the standard means of evaluating curve flexibility before surgery in idiopathic scoliosis. A push-prone radiograph also has been obtained at the authors' institution as a single dynamic radiographic assessment of forced correction of the primary curve and resultant effects on compensatory curves above and below the fusion. METHODS: Preoperative standing, supine right and left lateral-bending, and push-prone radiographs were performed in 40 patients who underwent anterior spinal instrumentation and fusion. Postoperative standing radiographs of the spine were obtained at 3 months after surgery. Measurements on all the radiographs included the coronal Cobb angle, the angle of the lowest instrumented vertebra to the horizontal, the rotation of the lowest instrumented vertebra, and the distance of the midpoint of the lowest instrumented vertebra from the center sacral line. RESULTS: The lateral-bending and the push-prone radiographs predicted less correction of the Cobb angle and the angle of the lowest instrumented vertebra to the horizontal than was achieved after surgery. However, the push-prone radiograph was superior to the lateral-bending radiograph in accurately predicting the postoperative correction of the rotation of the lowest instrumented vertebra as well as the translation of the lowest instrumented vertebra from the center sacral line. CONCLUSIONS: The push-prone and lateral-bending radiographs are similar in predicting less correction of the Cobb angle after anterior spinal surgery. The push-prone radiograph helps in determining the effects that correction of the primary curve has on the curves above and below the level of fusion by better predicting the translational correction of the lowest instrumented vertebra and the rotation of the lowest instrumented vertebra.

Comparison of standing sagittal spinal alignment in asymptomatic adolescents and adults.

STUDY DESIGN: A retrospective examination of the spine radiographs of 88 asymptomatic adolescents was performed to analyze the indices of regional and segmental sagittal spinal alignment in relation to the sagittal vertical axis as determined by the C7 plumb line. OBJECTIVES: To determine the sagittal spinal alignment in asymptomatic adolescents and to correlate the sagittal vertical axis with the overall sagittal spinal balance and other indices of sagittal spinal alignment. In addition, to compare these results with previously established data for asymptomatic adults. SUMMARY OF BACKGROUND DATA: Previous studies of sagittal spinal alignment have included subjects encompassing a wide range of ages. A previous study at the authors' institution established normative data for sagittal spinal alignment in asymptomatic adults. No previous study has reported on the correlation between the sagittal vertical axis and other measurements of sagittal spinal alignment in asymptomatic adolescents. METHODS: Measurements obtained from the standing lateral spine radiographs of 88 asymptomatic adolescents (age range, 10-18 years) were collected and analyzed using statistical methods. These data were compared with previously established data for asymptomatic adults. RESULTS: There was a striking similarity in regional thoracic kyphosis and lumbar lordosis between adolescents and adults. Despite having similar regional and segmental sagittal alignments, adolescents had a significantly more negative sagittal vertical axis (mean, -5.6 cm) than adults (mean, -3.2 cm; P = 0.0001). Also, unlike that in adults, the sagittal vertical axis in adolescents was not significantly correlated with the distal segmental lumbar lordosis. The sagittal vertical axis in adolescents was significantly correlated with the level of thoracic kyphosis and the distances from the thoracic apex, lumbar apex, and T12 to the C7 plumb line. Sacral inclination, which is a determinant of hip extension and standing pelvic rotation, was correlated with the lumbar apex and the total and segmental lordosis, except at L5-S1. CONCLUSIONS: Asymptomatic adolescents tend to stand in greater negative sagittal spinal balance than asymptomatic adults, despite similar regional and segmental alignments in the thoracic and lumbar spine. The role of hip extension, spinopelvic axis rotation, and other sagittal alignment parameters in determining the sagittal vertical axis in adolescents warrants further study.

The effect of variation in arm position on sagittal spinal alignment.

STUDY DESIGN: A prospective radiographic analysis of sagittal alignment in patients with and without previous spinal fusion. OBJECTIVES: To evaluate the effect of variation of arm position on the segmental, regional, and global sagittal radiographic spinal alignment. In addition, to determine whether spinal fusion has any influence on the effect of variation in arm position on the sagittal spinal alignment. SUMMARY OF BACKGROUND DATA: Importance of segmental, regional, and global sagittal alignment has been widely promoted. However, no mention has been made of arm positioning during a lateral spinal radiograph and the resultant effects it may have on sagittal alignment and balance. METHODS: Prospective evaluation of 40 consecutive patients with and 40 consecutive patients without a previous spinal fusion was performed. The patients had lateral long cassette radiographs performed in a standardized fashion with the first radiograph obtained with the patient's arms raised horizontally forward at 90 degrees of flexion at the shoulder, and the second radiograph obtained with arms raised horizontally forward at 30 degrees of flexion at the shoulder. Standard segmental, regional, and global sagittal alignments were measured and statistically compared. RESULTS: In comparing group 1 (patients with spinal fusion) to group 2 (patients without spinal fusion), there was no statistically significant difference in segmental and regional sagittal alignments. However, positioning the arms at 90 degrees versus 30 degrees resulted in a negative shift of the sagittal vertical axis (SVA) in patients that was statistically significant (P = 0.038) for those with (-6 mm at 90 degrees vs +4 mm at 30 degrees ), but not (P = 0.119) for those patients without (-8 mm at 90 degrees vs -4mm at 30 degrees ) a previous spinal fusion. CONCLUSIONS: Based on the findings in this study, the authors recommend positioning the arms at 30 degrees of forward flexion from the vertical when obtaining a long cassette lateral radiograph of the entire spine.

A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis relative to the surgical approach used for spinal arthrodesis.

STUDY DESIGN: A prospective evaluation of pulmonary function in patients with adolescent idiopathic scoliosis undergoing surgical correction. OBJECTIVES: 1) To evaluate prospectively, at regular intervals, the changes in pulmonary function after surgical arthrodesis of primary thoracic and double primary thoracic-lumbar (double major) types of adolescent idiopathic scoliosis in a homogeneous population; 2) to compare the changes in pulmonary function after surgical correction relative to the surgical approach used for spinal arthrodesis; and 3) to determine if short- to midterm morbidity with respect to pulmonary function is associated with the type of surgical approach used for spinal arthrodesis. SUMMARY OF BACKGROUND DATA: The effect of surgical correction on the pulmonary function of patients with adolescent idiopathic scoliosis is controversial. Studies have shown improvement, decline, or no change in pulmonary function after surgical correction of idiopathic scoliosis. METHODS: Ninety-eight patients with adolescent idiopathic scoliosis undergoing surgical treatment at the authors' institution were prospectively evaluated with pulmonary function tests assessing volume (forced vital capacity and total lung capacity) and flow (forced expiratory volume in 1 second). Pulmonary functions were evaluated before surgery and after surgery at 3 months, 1 year, 2 years, and at the final follow-up visit. All patients were divided into four groups depending on the surgical approach used for spinal fusion: Group 1 (n = 47) underwent a posterior spinal fusion with iliac crest bone graft; Group 2 (n = 33) underwent a posterior spinal fusion with rib resection thoracoplasty; Group 3 (n = 7) underwent an anterior spinal fusion with a rib resection thoracotomy; and Group 4 (n = 11) underwent a combined anterior and posterior spinal fusion with autogenous rib and iliac crest graft used, respectively. RESULTS: Patients in Group 1 had improved pulmonary function values at 3 months after surgery, whereas patients in Groups 2, 3, and 4 showed a decline at 3 months after surgery. Two years after surgery, Group 1 had significantly improved pulmonary function values (P < 0.0001), whereas the pulmonary function values of patients in Groups 2, 3, and 4 had returned to preoperative values. CONCLUSIONS: 1) Patients with chest cage disruption during surgical treatment showed a decline in pulmonary function at 3 months after surgery. 2) In contrast, patients without chest cage disruption showed an improvement in pulmonary function at 3 months after surgery. 3) Irrespective of the surgical approach used for spinal arthrodesis, postoperative pulmonary function tests (absolute values) returned to preoperative values at 2 years after surgery. 4) Patients who had no chest cage disruption experienced a significantly greater improvement in two of their pulmonary function values at 2 years after surgery than patients with chest cage disruption.

Complications in the adult spinal deformity patient having combined surgery. Does revision increase the risk?

STUDY DESIGN: A comparison of short-term complications (within 6 months after surgery) between primary combined adult spinal deformity (multilevel scoliosis, kyphosis, fixed coronal-sagittal imbalance) surgeries (n = 18) and combined adult spinal deformity revision surgeries (n = 26). OBJECTIVES: To analyze the short-term complications and to determine whether revision status increases the risks of short-term complications in this group of patients. SUMMARY OF BACKGROUND DATA: There is no peer-reviewed article comparing complications of revision to those in primary patients in a group of patients undergoing combined surgery for adult spinal deformity. METHODS: Major and minor complications were analyzed for both patient groups, and demographic data were collected. The demographic data of the two groups were very similar. RESULTS: The major (11.1% vs. 7.8%) and minor (11.1% vs. 11.5%) complications for the two groups (primary vs. revision) were very similar. All patients had combined procedures and all were patients with adult spinal deformity. The wound complications were less in those receiving total parenteral nutrition (2 of 31) than in those without (2 of 13). The group receiving parenteral nutrition was thought to be at higher risk for wound complications. CONCLUSIONS: The risk of major and minor complications within the first 6 months after surgery is not necessarily greater in the revision group than in the primary group of patients with adult spinal deformity who have combined surgeries. Total parenteral nutrition does appear to have a role in many of these patients.

Multiple noncontiguous injuries of the spine in a child: atlantooccipital dislocation and seat-belt injury of the lumbar spine.

Multiple noncontiguous injuries of nonadjoining regions of the spine in children are rare. Such injuries can be overlooked as the neurological deficit caused by one injury can be masked by the other. The combination of atlantooccipital dislocation and a seat-belt injury of the spine in children is rare. We describe an unusual case of atlantooccipital dislocation in combination with a seat-belt injury of the lumbar spine in a surviving child. Early halo-vest immobilization was an effective treatment in this patient. Although survival with atlantooccipital injuries is becoming common, severe and persistent neurological deficits can result in high morbidity. A brief description of the pathomechanics, diagnosis and treatment of the atlantooccipital dislocation and lumbar seat-belt injury is given.

Skull base hydatid cyst with intracranial extension presenting as vocal cord palsy: a case report.

Hydatid disease of the skull base is extremely rare, and intracranial extension of hydatid cysts through the skull base is even rarer. We report an interesting case of a 42-year-old man who presented with features of right vocal cord palsy. The diagnosis of hydatid cyst was made based on his history and on pre-operative MRI and was confirmed by surgery and histopathological examination.

The fully hydroxyapatite-coated total hip implant. Clinical and roentgenographic results.

The clinical and roentgenographic results of 54 fully hydroxyapatite (HA)-coated primary total hip arthroplasties in 45 patients was studied. Both the femoral and the acetabular components had a 200-microns coating of hydroxyapatite. The mean age of the patients was 54.8 years. Twenty-three patients were between 45 and 60 years of age. There were 24 men and 21 women. Nine patients under-went bilateral operations. The average follow-up period was 46.9 months (range, 24-78 months). The average preoperative Harris hip score was 48, and the average postoperative Harris hip score was 94 at 1 year and 96 at 2 years. Revision surgery for component loosening and infection was carried out in four (7.4%) cases. There was aseptic loosening of the femoral component in one case (1.85%) and of the acetabular component in two cases (3.7%). Roentgenographic evaluation indicated that greater stress transfer occurs in the distal two thirds of the femoral stem. Proximomedial femoral neck resorption was noted in 23 cases (57.4%). Excellent to good clinical outcome was obtained in 89% of patients. In the short term, the rate of aseptic loosening of the fully HA-coated hip prosthesis in our series is higher than the reported rates of aseptic loosening of proximally HA-coated total hip implants. Controlled clinical studies would be required to evaluate the relative efficacy of the fully HA-coated and the proximally HA-coated hip prostheses.

Dynamic ultrasound assessment for monitoring of treatment of congenital dislocation of the hip.

Of the 7,827 babies born in Sheffield between March 1989 and August 1991, a total of 114 (1.4%) who had either clinical abnormality of the hip or high-risk factors for congenital dislocation of the hip (CDH) were examined by ultrasound at birth and at regular intervals. Dynamic ultrasound assessment of both hips was done to diagnose instability and to monitor the treatment. Abnormal findings were recorded in 55 babies at the first visit, and 31 of these subsequently required treatment with the Pavlik harness (3.9 per 1,000). Only one case of late CDH has been seen among the babies who were not examined by ultrasound. There were no cases of avascular necrosis in our series. Dynamic ultrasound examination of high-risk infants' hips is a reliable method of screening for CDH. Monitoring of hips treated with the Pavlik harness, by dynamic ultrasound examination, can identify failure to obtain a concentric reduction, and in such cases, splintage can be abandoned in favour of other modes of treatment. It can, therefore, reduce the chances of overtreatment and its associated complications.

Click evoked otoacoustic emissions in adult subjects: standard indices and test-retest reliability.

The present study was designed to evaluate transiently evoked otoacoustic emissions in an otologically normal adult population. Using the ILO 88 Otodynamic Analyzer, the recorded otoacoustic emission responses were analyzed for five parameters. Considering the variability of instrumentation and technique in otoacoustic emission testing, we have defined a normative data pool using standard commercially available testing equipment. These data should facilitate comparison with data acquired in various pathologic states. The test-retest validity of this procedure also was evaluated and was found to be high. Use of click evoked otoacoustic emissions, with some caveats, appears to be a promising technique for further research into the assessment of normal/abnormal cochlear function.

Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders.

We studied the results of 140 STA-peg arthroereisis procedures performed for the treatment of planovalgus foot deformity in 78 ambulatory children with neuromuscular disease. Patient age at surgery ranged from 2 + 2 to 14 + 11 years, with a mean of 7 + 9 years. Patients were followed up for an average of 4 + 6 years. The ultrahigh-molecular-weight polyethylene (UHMWPE) STA-peg implant is inserted laterally into the subtalar joint such that its stem extends inferiorly into the calcaneus and its collar abuts the inferior surface of the lateral process of the talus, thereby blocking excessive valgus tilt of the calcaneus. All but five patients (nine feet) had concomitant soft-tissue procedures to balance the foot. The talocalcaneal angle and the talar declination angle were measured on lateral radiographs preoperatively, postoperatively, and at the latest follow-up visit. Patients were evaluated for the presence of pain and hindfoot valgus deformity. Satisfactory results were achieved in 135 (96.4%) feet. Results were unsatisfactory in one foot of each of five patients who had bilateral procedures; one was painful, and four developed varus. The STA-peg was removed in these five patients. No infections or adverse tissue reactions to the STA-peg implant were observed. STA-peg arthroereisis, combined with satisfactory muscle-balancing procedures, can predictably achieve control of planovalgus foot deformity in children with neuromuscular disorders and may obviate the need for long-term orthotic wear.

Pemberton osteotomy for the treatment of developmental dysplasia of the hip in older children.

A retrospective analysis was done of the results of the Pemberton osteotomy for the treatment of developmental dysplasia of the hip in 16 hips of 14 children older than 7 years. The average age of the patients at the time of surgery was 11+6 years and the average follow-up was 4+10 years. Eleven hips required one or more surgical procedures concomitant with the Pemberton osteotomy to achieve a concentric and congruous reduction of the hip joint. None of the hips developed avascular necrosis of the acetabular fragment. The center-edge angle improved from a preoperative average of 1 degree to an average of 30 degrees at the most recent follow-up. Correction of acetabular dysplasia was noted in 14 of the 16 hips, as demonstrated by the improvement in the acetabular index, the center-edge angle, and the Severin class. We believe that the Pemberton osteotomy can be a safe and effective procedure for the treatment of developmental dysplasia of the hip in the older child.

Aneurysmal bone cyst of the clavicle in a child.

We report a case of an aneurysmal bone cyst (ABC) of the clavicle in a 9-year-old boy, which initially presented as a pathological fracture of a benign cystic lesion. ABC of the clavicle is rare in children less than 10 years old and radiological diagnosis may prove difficult in the early stages of presentation.

Polyarticular pigmented villonodular synovitis in a child.

Pigmented villonodular synovitis is rare in the younger child. Polyarticular involvement in this condition, regardless of patient age, is distinctly uncommon. The authors describe a case of pigmented villonodular synovitis involving multiple joints in a young boy who also had congenital anomalies of the genitourinary tract. Although rare, pigmented villonodular synovitis should be considered in the differential diagnosis of multiple joint swellings in children with congenital anomalies.